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Email* This field is required.Sample@SampleEmail.com
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Phone* This field is required.(555) 555-5555
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Is your mailing address the same as your home address?* This field is required.
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Enter your mailing address, if it is different than home address* This field is required.NO P.O. BOX
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7
Select your service location* This field is required.
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Virtual Visit
Iron Culture Gym: 7700 River Rd, North Bergen NJ
Itserga Medical Offices: 181 Franklyn Ave, Nutley NJ
Modern Aesthetics Spa: 125 River Road, ST 105. Edgewater NJ
XCel Sports & Fitness Gym: 25 Greenbrook Rd, Fairfield NJ
8
What is your Instagram URL?ex: instagram.com/username
9
Date of Birth* This field is required.
Date
Month
Day
Year
10
Sex* This field is required.
Male
Female
Non-binary
11
Height* This field is required.Feet' Inches"
12
Current Weight in LBS.* This field is required.
13
Pharmacy Address* This field is required.
Street Address
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Afghanistan
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Canada
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Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
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Iran
Iraq
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Israel
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Jamaica
Japan
Jersey
Jordan
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Kenya
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Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
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Malawi
Malaysia
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Mali
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Martinique
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Niue
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Northern Mariana
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Palau
Palestine
Panama
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Peru
Philippines
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Poland
Portugal
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Romania
Russia
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Saint Vincent and the Grenadines
Samoa
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Sao Tome and Principe
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Senegal
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Tanzania
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Timor-Leste
Togo
Tokelau
Tonga
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14
Indicate some of your goals* This field is required.Indicate all that apply
Increase growth or muscle mass
Increase endurance, energy
Increase libido
Be accountable
Weight loss
Anti-aging treatments
Preventive measures
Gut Health & Reduce Bloating
15
Indicate what are some of your challenges* This field is required.Indicate all that apply
Anxiety
Decrease of desire or low libido
Hair thinning, loss
Brain fog
Menopause
Weight gain
Sleeplessness
Body or joint pain
Bloating
Water retention, swelling
16
How long have you've been experiencing these issues?* This field is required.
0-6 Months
6-12 Months
12 Months or more
17
Symptoms Severity?* This field is required.
Mild
Moderate
Severe
18
Services of Interest* This field is required.indicate all they apply
Medical Weight Loss
Hormone Replacement Therapy
Sexual Health
Stem Cell & Exosome Anti-Aging
Improve Skin Appearance
Fillers / Botox
PNOE Metabolic Testing
Cupping and Detox
Gut Health
Cryotherapy
Flexibility / Mobility / Stretching
Accountability Coaching
19
Are you currently taking any medications? If so, list below.Please note some medications may alter your bloodwork results. Please be detailed so we can advise fasting and preparation rules for the blood draw.
Huge
Large
Normal
Small
Ok
Ok
20
Upload a picture of the front of your Drivers License or Government Issued I.D.* This field is required.
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Cancelof
21
Do you have health insurance?* This field is required.HNW Rx is a membership-based program and does not accept insurance. However, bloodwork should be covered by your health insurance. Please contact your insurance provider for any additional questions.
YESNO
22
What lab is covered under your insurance?* This field is required.We require this information to fill out the proper lab requisition for bloodwork. Contact your insurance provider if you have an concerns.
LabCorp
Quest
Other
NONE
23
Where would you like to go for lab work?* This field is required.We require this information to fill out the proper lab requisition for bloodwork. Contact your insurance provider if you have an concerns.
Home Draw - Phlebotomist comes to home (Cigina not accepted)
LabCorp - all locations
Quest - all location
24
Upload a picture of the FRONT of your insurance card, for verification.* This field is required.
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Select files to upload
Cancelof
25
Upload a picture of the BACK of your insurance card* This field is required.
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Cancelof
26
Upload most recent blood work or scans, if you have.
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Cancelof
27
We offer support for all budgets and, goals. What would be your ideal level of support?* This field is required.Select your preferred level of support. Our Level of Support is a monthly membership with a 12-month agreement and a monthly commitment. Membership does NOT include the cost of medication costs. HSA & FSA, and financing options are available. Remember, this information is provided with no obligation to commit to membership.
💪 $139/month – ELEVATE À la carte Meds & Supplements. Just want the essentials? ELEVATE gets you full access to our wellness protocols, and you pay as you go for medications, peptides, and supplements. No frills, no discounts—just results. It’s the “I’m in control” plan.But… if you’re looking for real perks 👇
🔥 $249/month – LIFESTYLE CONCIERGE MembershipAll Protocols + Direct Primary Care + Extended Hours & ServicesPLUS 15% OFF ALL Medications, Peptides & SupplementsThis is where the magic happens. Total access to everything we offer—with VIP treatment. You get longer hours, personalized care, priority service, and savings that stack up fast.If you're serious about your health, energy, libido, and longevity—this is your move.✅ Premium access✅ Concierge-style support✅ Real savings that pay for the membership itselfInvest in yourself—because average plans get average results.
28
Terms and Acknowledgments:* This field is required.I understand that there is no obligation to move forward, and my decision is entirely voluntary. I acknowledge that it is my responsibility to check with my insurance provider to confirm coverage. HNW Rx is not responsible for any lab billing. In the absence of health insurance coverage, I may request an abbreviated lab requisition from HNW Rx. I understand there is a non-refundable one-time fee of $275 for the initial lab review, due at the time of booking an appointment. Following the review, Dr. Agresti and his team will create a protocol tailored to my needs. I have the option to approve, adjust, or choose not to proceed, and there is no commitment or additional cost if I wish not to move forward. Moving forward, I understand that quarterly lab review payments are included in my membership. Please select 'Yes' if you agree to the terms mentioned above, or 'No' if you choose not to proceed at this time.
YESNO
29
Ready to move forward?* This field is required.
Yes. Provide me with details on the next steps for obtaining bloodwork.
Not quite. Please have a Wellness Advisor contact me.
30
HIPAA Compliance Consent* This field is required.Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such revocation will not be retroactive. I understand that: SELECT ALL BOXES BELOW
Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon the execution of this consent.
31
Terms and Conditions* This field is required.
32
How did you hear about us?* This field is required.
Instagram
FaceBook
Internet
Foundation Rx
Fiona Rooney Health
ICandy Meals
The Feel Good Labs
XCell Gyms
Metropolitan Social Club
OTHER
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